Rixa has an excellent post up at her blog Stand and Deliver. She wrote about yet another obstetrics practice that is refusing to allow their clients to bring a doula, but is forcing them to sign a birth plan that says episiotomies may be used to prevent tears, among other evidence free ridiculousness.

What is even worse, two commenters defend this position, with unsubstantiated statements that assume that doulas are somehow dangerous, and these interventions are what ensure a healthy baby and healthy mom. One of these commenters claims to be a physician!

I wrote a reply:

Argh, this is so frustrating. Rixa, excellent post. I have some points in response to the actions of the Kingsdale Gynecologic Group, their birth plan, and the replies from “B” and the anonymous physician.

First, I’d like to point out that using a doula as they currently exist, with their current level of training and lack of licensure, has been rated as one of the most effective labor interventions for improving birth outcomes, based on excellent evidence. Here is the article by Berghella et al on Evidence Based Labor and Delivery Management that covers this intervention (along with many of the other interventions mentioned in the original post and the comment thread.) It states that having a doula is one of the most effective interventions available. How a physician could criticize this practice, which has an evidence rating of A, but defends analgesia, which has no positive effect on birth outcomes, is beyond me.

Doulas are not immune from liability. They can be sued just like any other individual. They do not provide medical treatment, so do not need to carry malpractice insurance. I think that is a bizarre idea. Nurses, including labor nurses, do not carry malpractice insurance. Why should doulas, who simply provide emotional support and information?

Also, how does it make medico-legal sense to deny women the choice of an evidence based intervention that improves outcomes (doulas), but support interventions that are shown by copious evidence to be harmful (episiotomy) or are non-evidence based and have even been questioned in recent editorials in ACOG’s Green Journal (depriving oral nutrition during labor)? Who needs to “get their priorities straight”? If “[t]he important thing is a safe and healthy delivery for both the infant and mother”, why not support the evidence based interventions like doulas, especially if it is what the woman wants, instead of insisting on harmful or questionable interventions? (Sources: JAMA’s Outcomes of routine episiotomy: a systematic review, which says episiotomy is more harmful than helpful, and should be “avoided at all costs”, and the Cochrane Review on Restricting oral fluid and food intake during labour, which concludes that “women should be free to eat and drink in labour, or not, as they wish.”)

And, how are ALL birth plans nonsense? With obstetricians refusing access to doulas, encouraging episiotomies, and restricting food and fluids, what are we classifying as nonsense? How about when obstetricians induce women who are 39 weeks gestational age (if they wait that long!), with no medical indication for induction, and have a low Bishop’s score? Then, they are put in the hospital, told they cannot ingest anything but ice chips, and their induction takes several days (due to the unfavorable cervix). Let’s say they have only lactated ringer’s solution in their IV, so they are not receiving any glucose for 48 hours. If the woman has no glucose, her blood sugar will plummet and she may get an altered mental state. That, plus pitocin augmentation, may lead to the frequent request for analgesia in patients that originally intend to try to avoid unnecessary medication. I wish this was uncommon. Are you really suggesting that a birth plan is nonsense here? Or the current standard of care? The Listening to Mothers survey indicates that these interventions are all too common.

I find it really disheartening that people, including a physician and a gynecologic group, will defend harmful and baseless interventions, simply to bolster a paternalistic model of care, instead of an evidence based practice such as hiring a doula.

Love this post! It’s so clear when you lay it out: Doulas, evidence-based, but a challenge to the system as it currently operates – DANGEROUS. Episiotomy, non-evidence-based, fits neatly into a paternalistic model of care – A-OK.

I had someone else tell me the other day that mothers who come in with birth plans “get everything they didn’t want” and are “guaranteed a c-section” and are “too anxious”. I really want some research on this, if only to investigate my hypothesis that people are only noticing their own routine practices when someone has explicitly said “please don’t do this”…

Absolutely. Based on my research and published literature, it seems that physicians are more likely to support and use interventions based on how they increase their own autonomy, instead of whether the intervention is evidence-based and/or desired by the patient.

Writing a birth plan gives you an opportunity to think about and discuss with your partner and your health care practitioner how — ideally — you’d like your baby’s birth to be handled. Even though there’s no way you can control every aspect of labor and delivery, a printed document gives you a place to make your wishes clear. Just remember that you’ll need to stay flexible in case something comes up that requires your birth team to depart from your plan.

As much as I understand why doulas make some physicians uncomfortable, I still have a hard time wrapping my head around the uber-strong evidence for doulas, versus the persistent resistance to them among some physicians. The evidence for doulas is some of the clearest and strongest out there, yet physicians (and some of the lay public) argue that “for the safety of mother and baby, be careful of bringing a doula into the delivery room.”

Did you turn it into a separate post? I don’t blame you. That sort of anti-patient rationalization and bundle of contradictions is such an outrageous travesty to be coming from a self-described physician.

Sorry I am so behind – my blog reader is burgeoning. This post of your I link to is from late June! I am still trying to catch up.

Doulas are indeed positive and many medical sociologists find that women who incorporate the use of them into their BIRTH PLANS feel more in control and have LESS FEAR AND FAR LESS REPORTED PAIN. Anyone who goes through the process of birth with less anxiety and less pain is going to have a more positive outcome.

Right on – be a better doctor. Stand for what is right against the tide of “the old paradigm.”

Yeah, so do I! I was lucky enough to be assigned a midwifery student as a doula, and she gave me continuous labor support, for my second delivery. I can’t tell you how much better it was than my first delivery.

The first time around, I had my husband and my mom with me, and a CNM as my practitioner, but I was clueless and scared. I was given pitocin (even though I was hardly stalled) and forced to lie flat on my back with continuous monitoring. I was coached to push for three hours against an inflamed lip instead of being allowed to labor down. Then, my baby was whisked away for four hours as I cried and wondered why something that was supposed to be so wonderful felt so disempowering, even though my experience was hardly traumatic compared to many hospital births.

The second time around, the doula / student informed me and reassured me throughout the entire labor, I was monitored with intermittent monitoring, encouraged to eat and drink and change positions, allowed to labor in a warm tub, and my desire to labor down was honored. I pushed for 18 minutes instead of three hours! My son was put right on my chest after the delivery, and was never separated from me. I didn’t know what a doula was, didn’t know the evidence saying intermittent monitoring is as good as continuous monitoring, etc., but I benefited from all of these evidence based practices.

Right before the OB cut the episiotomy required (acc to her) to use forceps to deliver my daughter (at the time, it seemed better than a c-section, but now I’m not so sure), I was worried that I would feel the cut (which was a ridiculous thing to worry about since the epidural I had on board was so strong I was unable to push). In a vain attempt to reassure me, the OB said “oh, and episiotomies heal better than tears anyway”.

What I wanted to say in response was “don’t make me pull out the Cochrane review on you” but then it seemed ludicrous that I would have to say something like that with my feet in stir-ups about to have some salad-tongues stuck into me.

I’m sorry, women about to give birth shouldn’t have to have arguments with doctors about scientific literature. What are we paying them for anyway?

And, I completely agree w/VW… women who are laboring/pushing/birthing a baby should not have defend their position of declining an intervention by stating literature to the obstetrician (or midwife). Even if they do, most OBs will ignore this anyhow. I find they do this to me when I have to defend the management of my own laboring women!

I think you might have been misinterpreting what I was saying. Well, I suppose I was looking for a compromise between current medical practices that are routine and what evidence has shown for the majority of low-risk birthing women. e.g. Agreeing to a heplock but saying no to routine IV. A heplock would be very useful in case of pph, yet it doesn’t restrict a woman in labour so long as she isn’t hooked up to an IV. Really, I do agree that it would be ideal for hospitals and medical staff to be following evidence-based care.

We didn’t have a grandmother or a mother or really anyone experienced to help us. I felt it was very valuable to have a doula who had been through many. I believe my wife felt so too. (Two births, same midwife, in a hospital setting, with much thanks to Jerry Brown and the midwives who made it legal and raised my awareness 15 years before the kids were born.)

When creating a birth plan you must not make the mistake of making the plan a set of orders as to what you expect others to do. What you need to do is to provide clear and unambiguous instructions regarding what needs to be done while you are in labor and also while the actual birth is taking place. This means that for the plan to be useful it must address a few important issues.

My birth plan is pretty simple.
Basically just, no med’s or procedures (routine or otherwise) will be done without explanation of what they are, their benefits and risks, and permission given by me. Unless It is immediately necessary to save my life or baby’s.
Baby is not to be separated from me for any but life/death reasons. And accompanied by my husband in that case.
Then at the end I have a ‘wish list’ I made it clear that it is just a wish list, that if medically impossible, or other circumstances come up including my deciding against it when the time comes, that I will give up these wishes with only the assurance it was very necessary to forgo the wish. On my wish list are things like, I would like to catch baby, do the ‘breast crawl’, delay all but the most cursory infant exams until after the first nursing.
I remember reading Rixa’s post and being even happier in my decision to have a birth center birth again. I know most OB’s are great, but most of the ones in my area are very old fashioned and hold a very paternalistic view of care. There is even one perv who I’ve heard some gag inspiring stories about from a woman on whose word I trust implicitly, not quite sure how he is still in practice. But needless to say, I don’t live in a great area to find a good OB so unless you want little to no control over your birth a midwife is your only option. I know it isn’t true in all area’s, but it is fact here. and it makes me sad for the women who can’t deliver with midwives here because of health or insurance issues, or lack of knowledge/ support.
I have a feeling this reply is a little rambling…hope you can make some since out of it.